2 October 2017

AMA: euthanasia and marriage equality demand our attention

This article was first published on 20 September, 2017, by Huffpost, here.

IN recent months, we have seen concurrent discussion on two different social and health issues – namely euthanasia/physician-assisted suicide and marriage equality/same-sex marriage.

Perhaps the reason they have been grouped together is because of the support that both these issues have from the so-called progressive left, and the presumed opposition of so-called conservative religious forces. Despite this, the two issues could not be more different.

Exactly how and when euthanasia became a progressive left issue is difficult to understand. A societal change that threatens the most vulnerable people, those without a voice, while prioritising the rights of the individual might appear to be ideologically closer to the right.

It has long been recognised that doctors who are closest to providing end-of-life care are those most likely to be opposed to physician-assisted suicide. The Australian Medical Association’s own member survey, which informed the 2016 update to its Position Statement, showed that the groups most likely to favour a change are younger doctors and those who rarely treat dying patients.

While the AMA did not actively survey our members on marriage equality (a decision that has been criticised by those opposed to it), our Position Statement on this issue enjoys the broad support of the profession. The commentary for and against it reflects the great diversity in the medical profession. The AMA position is most popular among young doctors.

I have no doubt that legislating for marriage equality would be a positive move for our community. It will remove one of the final vestiges of discrimination against a minority in our society. It will further legitimise civil unions that already exist. It is a vote for love, and a vote for family as the fundamental unit of social support in society.

Discrimination has negative mental and physical health outcomes. While not all of our members agree, the AMA supports legislation of marriage equality.

On the contrary, the proposal for Voluntary Assisted Dying in Victoria, or any other form of euthanasia/physician-assisted suicide in NSW, WA, or elsewhere, would be a negative move for our society. It would be a victory for fear over hope, and would in no way enhance the provision of quality end-of-life care.

The way we look after our elderly is simply not good enough. It is a stain on our society that we do not invest in aged care like we invest in, and celebrate, technological advances in medical procedures and new pharmaceuticals.

This week, I had it put to me that influenza deaths in residential aged care facilities are acceptable. They are not. Elder abuse is real, and it happens every day.

The sick, the elderly, the disabled, the chronically ill and the dying must never be made to feel they are a burden. They reflect a diversity in our society that is every bit as important as the LGBTQ community.

Patients receiving high quality palliative care rarely, if ever, request euthanasia/physician-assisted suicide. The Voluntary Assisted Dying committee in Victoria was tasked with implementing Recommendation 49 of the Upper House committee report. The first 48 recommendations might have been better put first. Euthanasia/physician-assisted suicide makes us a poorer society, not a richer one.

I disagree with those opposed to marriage equality. No one is harmed. There are no casualties. It need not threaten religious freedom, and it is something generous and positive that the community can do in support of, and in partnership with, a minority group – a group that includes our sons and daughters, brothers and sisters, friends and work colleagues.

On the other hand, euthanasia/physician-assisted suicide in no way makes our society safer or better. In other parts of the world, the legislation has been changed so it can be used against vulnerable groups. In the Netherlands and Belgium, it has been extended to involve children. In other jurisdictions, it can be used against the disabled and the demented.

Unlike marriage equality, end-of-life care is an issue for the majority of the population.

While not all our members agree, the AMA opposes any interventions that have as their primary intention the ending of a person’s life.

So, to the parliamentarians, and to the people of Australia, I ask you to think deeply and deliver positive choices that make us a richer society, a better society, a more caring and ethical society. Resolving these two critical areas of public debate is an opportunity to show exactly how much we care about our fellow citizens.

Dr Michael Gannon is national president of the Australian Medical Association. He is an Ob/Gyn at St John of God Subiaco Hospital in Perth, WA.

MJA InSight and the Medical Journal of Australia are owned by, and editorially independent of, the Australian Medical Association.

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.

I am sad to see the President of the AMA,Dr Gannon, use his position to present a biased attack on the proposal to legalise Voluntary Assisted Dying (VAD).
The AMA VAD survey and other medical bodies surveys on VAD have shown the medical profession to be fairly evenly split on the issue of legalising VAD.
The experience overseas has shown that once VAD is legalized most doctors support the legalisation of VAD.
In those US states ,like Oregan, and several European countries where VAD has been legalised with the same safeguards as proposed in the Victorian state legislation there has been none of the problems opponents of VAD have used in their scaremongering opposition.
It is to be hoped in the future that AMA spokesmen will not present biased personal beliefs as arguments against VAD.
The least the AMA should do is allow a balancing opinion to be presented in support of legalising VAD by some one like Dr Brian Owler who has supported the Victorian VAD proposal.

Three socio-scientific issues have become heavily politicised; climate change, SSM and euthanasia.

Generally these are passionately supported by the groupthink of the “progressive left” , but viewed with thoughtfulness and a degree of scepticism by the more conservative in our society.

Euthanasia is in my view, a final frontier for the medical profession – once we condone or take part in this we risk losing the trust and respect of the community, and in my view later to be bitterly regretted.

I dispute Dr Marr’s assertion that most doctors would support legalisation of euthanasia. At the same time I don’t understand why some doctors are keen to see it introduced. It goes against our enshrined codes of medical ethics and risks abuse and normalisation of medically and legally-sanctioned killing.

Yes, euthanasia is a debate that we need to have. It takes wisdom and courage to meaningfully participate in a debate when we struggle to see the validity in the opposite argument to our firmly held position.

I work as a DBT informed psychiatrist with people who have treatment resistant disorders. The DBT approach is not palliative care however sometimes this non-palliative care treatment fails. There is no mental health palliative care treatments that work in the same reliable way that opiates do for physical pain. And given that many people in palliative care type of mental health treatments choose to suicide it would be useful to have a very seriously and dialectical discussion about this topic. Let’s pause and remember that eight people in Australia are likely to die by suicide today – alone and by means that are traumatic to themselves and the people who find their bodies. And, if the statistics are to be believed, one person every 6 minutes attempts suicide…

Please do not get me wrong here – I am not asking for a fast track for suicidal patients into euthanasia services – I am asking for a fast track into evidence based treatments with the back up option of a slow and well thought out track to euthanasia if properly administered evidence based treatments fail. Let’s not be naive here, much of our mental health treatment system is fractured and failing so a significant chunk of patients are by default dumped upon GPs.

There is a really significant paradox here; everyone’s brainstem is hardwired for survival. So in every euthanasia seeking patient, somewhere deep inside them, is an aspect of the person that can be worked on to assist the patient to choose life not death. It’s a paradox that for those people who suffer most psychologically, knowing that they have a choice of a painless and not alone death is of great comfort. Sometimes the euthanasia conversation crops up during our DBT treatment of highly suicidal patients. The present state of affairs is that the euthansia choice is via books offering the Final Solution one of which is via a plastic bag and some tape. I’ve had a high risk group patient die by this means probably secondary to his own research about how to achieve euthanasia. It may have been a very different outcome if I could have offered him a euthanasia pathway that required him to undergo a comprehensive evidence based treatment before the death option would be offered to him – because that treatment may well have worked. That chemo like treatment was not available to my patient, so it seems that the only option he felt open to him was to die alone without the dignity of appropriate farewells and in a way that left some poor soul to stumble upon his dead body.

The film Me before You seems to make some clear points that many who choose Euthanasia do so because they are psychologically unable to bear the physical pain or injury.

I would like to see medical leaders gently engage in a more meaningful discussion about this complex topic rather than espousing polarising opinions.

And in response to Dr Williams above; and so we are left to stand by whilst our patients live a life in intolerable psychic pain… that is not the type of medical professional that I want to be…

Oh boy, Pauline Cole, advocating euthanasia for mentally ill patients is opening up even more of Pandora’s Box; These are not “terminal” patients and even repeated attempts at suicide should not be an indication to assist them in these attempts. “Intolerable psychic pain” is incredibly subjective, may well be temporary. The literature is replete with accounts of patients attempting suicide at their peak of “psychic pain’ only to express extreme gratitude later that they were saved form this.

Dr Robert Marr says “In those US states ,like Oregan, and several European countries where VAD has been legalised with the same safeguards as proposed in the Victorian state legislation there has been none of the problems opponents of VAD have used in their scaremongering opposition”

I would also add that the legislation being proposed around Australia generally excludes the mentally ill and cognitively impaired. I feel these two groups who make up the vast majority of patients for whom palliative care may not be able to relieve suffering and assisted suicide could actually be useful. Unfortunately the risk of harm to this group makes it extremely hard to fully safeguard them under the law. Other patients eg cancer, heart failure, COPD, motor neurone disease, strokes are quite easy to provide palliative care for using the pre-existing palliative care. These patients invariably become sick and if life-prolonging care such as oxygen, antibiotics, fluids are withheld and replaced with opiates, palliative sedation using the so-called “secondary intent” the patient will die comfortably. Of course there are rare exceptions and sometimes people do die badly through inadequate palliative care. I don’t believe there is any patient whose pain/nausea/restlessness/distress is so uncontrollable that 1kg of morphine would not relive it even if it means their death through sedation. The patients who really cannot be managed well with traditional palliative care such as the patient with advanced cognitive impairment from dementia who is still physically well are the ones who would actually benefit from assisted suicide. Realistically there is no way to effectively safeguard those patients as we have seen in the examples provided.

Dr Williams; yes exactly – it is a Pandora’s box and we can place it in the too hard box and ignore it or we can gently and respectfully look at what’s inside and attempt to sort it out. Yes exactly, the literature may be replete with evidence for the straightforward cases but the literature is not so clear for the treatment resistant cases. I think that you may have missed the point that for mental health treatment resistant patients the freedom to choose can be something that eases suffering and can give people a kick into giving evidence based treatments a go. I would not expect understanding or agreement from those who stand in the polar opposite position, however that does not make this point of view invalid.

I would like to emphasise that I advocate for treatments that work, not for impulsive and unethical responses. I am experienced enough to know that much psychic pain is short term but some is definitely not. Not all suicides are impulsive, some are carefully thought out over many months or years of struggle whilst a patient is in ‘palliative care’ and giving the freedom to choose can remove a layer of suffering to let the effective therapeutic work begin. Those who repeatedly attempt suicide are often in chronic and intolerable pain.

People should be allowed to die with dignity at a place of their choosing.

Having worked in palliative care both in hospice and in the community, I do not see any contradiction between a “good death” with palliative care, and a “good physician assisted death”. Allowing people who have a terminal illness to choose the place and timing of their death gives them humanity and dignity.

Patients who wish to consider or choose to take this option on their own generally do not give the reasons of “being a burden”, but not wanting to lose their last tenets of independence and a fear that they will be too far gone to be able to act on their own. From experience, families are shocked and devastated that the patient has had to take the burden of this decision secretly in order to protect their family members from prosecution. The family may then have the ordeal of police interviews and a coroners inquest.

Allowing physician assisted end-of-life assistance would allow these patients and families to have what others in hospice palliative care are given – the preparation and knowledge that the end is near, an opportunity to say goodbye and a “good death” with care, love and dignity.

How many times do we meet unhappy elderly people who freely admit they are waiting to die ..
“I just want to die doctor. I’ve done all I want or can do, my kids are off my hands/I don’t have any and there is nothing now but to sit here and wait to die. I just hope it is soon.”

We think to ourselves “This is not how I want to end up and when my time comes, I hope I can chose.”
Most of us are living well beyond an age when nature would/should have snuffed us out because of general good health care, nutrition and our general medical smarts.

It is a real problem that many of us, for one personal reason or another, can not use the extra years that are now to be lived. Although we are living longer, it is inside increasingly decrepit bodies that we will sooner or later yearn to be released from. Particularly if we find ourselves in some of the so called nursing homes, sitting in a small room, desperately trying to remember or names, so we can write it on the walls in our own faeces.

Not all old people are running marathons, sky diving, dancing, travelling etc. Many just can’t.
I think it is quite reasonable that an elderly person, or anybody come to that, who has decided in all clear consciousness and for their own personal, logical, immutable reasons that they wish to chose how, where and when they die, (IMHO, the fundamental human right) should be able to do so.
Clearly remediable issues should be thoroughly investigated and if possible, remedied. However, if that person’s reason and logic is found to be sound, who are we to stand in their way?

Or would we prefer they jump off a bridge or lay down on a train track, with all the attendant gore and public pain that causes?

Terminally ill patients who are suffering intractable pain and/or distress despite receiving proper care should ( in this humane community) have the opportunity to choose a dignified, comfortable and timely mode of death which is legal for those who assist them and for themselves. Suicide with medical assistance under highly defined and controlled circumstances should be part of humane professional care for our patients should they choose it………it is not appropriate for religious and other groups who oppose physician-assisted suicide to impose their views on others who wish to have a good death of their own choosing

Religion should have no say in this issue at all, except for the members of their religion. The rest of us that were rejected by religion (I’m gay) should have every right to request Euthanasia whenever we feel we want it. I absolutely want to be able to choose death before being forced into a nursing home full of religious bigots that will do nothing but make what’s left of my life even more miserable. I’ve heard all kinds of nightmare stories about what happens to gay people in nursing homes. Right now, I can avoid the religious bigots by staying home and in my backyard behind a 6 foot privacy fence (and staying in the closet at work). But if my partner of 40 years should pass away before me, I want the right to request Euthanasia. Religious people need to butt out and keep their bigoted/hateful/judgmental crap to themselves. I’ve listened to their crap all my life and I absolutely don’t want to be trapped with them in a nursing home to be used as a punching bag at the end of my life..